Springfield Villa

Based on observation, interview, and record review, the facility failed to provide timely and complete urinary incontinence care for residents dependent on staff when staff did not check one resident (Resident #96) for incontinence for more than eight and one-half hours and did not provide complete and thorough perineal care for one resident (Residents #96). A sample of 29 residents was reviewed for personal hygiene and toileting needs. The facility census was 118. Review of the facility's policy titled Toileting Plans for Urinary Incontinence, undated, showed the following: -Purpose to provide guidance for the initiation and monitoring of and/or a toileting plan for the resident with urinary incontinence; -An incontinent management program involves checking the resident's continence status at regular intervals and providing incontinent care and garments as indicated by individual need. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Review of Resident #96's face sheet (brief resident profile sheet) showed the following information: -admission date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system was in place that clearly and consistently represented each resident's choice of code status (if they wished to receive cardiopulmonary resuscitation (CPR - lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped)) when staff failed to ensure two residents' (Residents #18 and #100) code status was consistent throughout the medical record. The facility census was 118.Review of the facility policy Advance Directive, dated [DATE], showed the following:-The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; -Upon admission of a resident, the social services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review , the facility failed to provide care per standards of practice when staff failed to promptly assess one resident (Resident #2) after a change in condition. The census was 123.Review of the facility's policy named, Event Investigation, undated, showed the following:-Purpose to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed and to identify any injuries after a resident sustains an event;-Handle resident gently, examine the entire skin surface, interview the resident to determine cause of any conditions identified, interview any witnesses to determine cause of any conditions identified, measure vital signs, assess pain, identify all skin discolorations, redness, swelling, edema (swelling), tenderness, breaks, or changes in temperature, measure the size, depth, color and location of any skin conditions identified, palpate peripheral pulses, gently perform passive and active range of motion of all joints,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure an environment as free from accident hazards as possible when staff failed to identify, assess, investigate, and document bruising of an unknown source for one resident (Resident #1). The census was 123. Based on observations, interview, and record review the facility failed to ensure an environment as free from accident hazards as possible when staff failed to identify, assess, investigate, and document bruising of an unknown source for one resident (Resident #1). The census was 123. Review of the facility's policy named, Event Investigation, undated, showed the following:-Purpose to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed and to identify any injuries after a resident sustains an event;-Handle resident gently, examine the entire skin surface, interview the resident to determine cause of any conditions identified, interview any witnesses to determine cause of any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

1.Please refer to event ID HP9H-H2, exit date 09/04/25, for citation details. Complaint #2572449 and #2586807

Deficiency Text Not Available

1.Please refer to event ID HP9H-H2, exit date 09/04/25, for citation details. Complaint #2572449 and #2586807

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to document regarding identification of potential pressure ulcers, failed to document timely assessment and tracking for potential pressure ulcers, and failed to care plan regarding newly identified possible pressure ulcers. The facility census was 116.Review of the facility policy titled Wound Care and Treatment, undated, showed prevention strategies include on-going skin assessment with weekly documentation of status, minimize dry skin by applying lotion, avoid massage, minimize friction and sheer through proper positioning, transferring, and turning, and develop and implement a method of communication position changing. Review of the facility policy titled Care Area Assessments, dated March 2015, showed the following: -Care area assessments (CAA's) will be used to help analyze data obtained from the MDS and to develop individualized care plans;-CAA's are the link between assessment and care planning;-Triggered care areas will be evaluated by the interdisciplinary team to determine the underlying causes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents' right to free from misappropriation was protected when medication of three residents (Resident #1, Resident #2, and Resident #3) went missing and were unaccounted for while in the possession of the facility. The facility had a census of 110. Review of the facility provided document titled, The National Consumer Voice Fact Sheet: Abuse, Neglect, Exploitation, and Misappropriation of Property, showed federal law gave each nursing home resident the right to quality care and quality of life. This included freedom from neglect, abuse, exploitation, and misappropriation of property. Review of the facility's Abuse Prohibition Protocol Manual: Identification, undated, showed the following: -It is the policy of the facility to identify, correct, and intervene in situations in which physical and mental abuse, neglect, adverse events, exploitation, mistreatment, involuntary seclusion, and/or misappropriation of resident's property may occur;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed ensure resident representatives were notified of changes in condition in a timely fashion when staff failed to document contact of one resident's (Resident #1) responsible party regarding changes in the resident's health condition. The facility census was 122.Review of the facility provided policy titled, Change in Condition of a Resident, dated 05/15/28, showed the following: -The facility is committed to timely recognition and response to significant changes in a resident's condition. This includes medical evaluation, appropriate interventions, family/representative and physician notifications, interdisciplinary collaboration, and updating the care plan and assessments as necessary to ensure the resident receives person-centered, high-quality care.-The resident's representative must be notified promptly, within 24 hours of the change in condition;-Documentation of notification must be in the medical record;-All assessments, physician communications, family notification, interdisciplinary meetings, and care plan updates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the failed to provide care per standard of practice when staff failed to document continued monitoring and assessment on one resident (Resident #1) with an ongoing change of condition resulting in new medication orders and a follow-up x-ray. The facility census was 122.Review of the facility policy titled, Change in Condition of a Resident, dated 05/15/28,showed the following:-The facility is committed to timely recognition and response to significant changes in a resident's condition. This includes medical evaluation, appropriate interventions, family/representative and physician notifications, interdisciplinary collaboration, and updating the care plan and assessments as necessary to ensure the resident receives person-centered, high-quality care;-Nursing staff must immediately report and document any suspected significant changes in the resident's status;-A licensed nurse must promptly assess the resident, document findings in the medical record, and notify the physician or nurse practitioner immediately, or within 24 hours;-All assessments,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote each resident's right to self-determination when the facility failed to complete showers/bathing to meet resident preferences for two residents (Resident #1 and #2). The facility census was 114. Review showed the facility did not provide a policy regarding showers/bathing. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 01/27/24 -Diagnoses included cerebrovascular disease (a group of conditions that affect the blood vessels in the brain, leading to reduced blood flow and oxygen supply to the brain), cellulitis (bacterial skin infection) of left lower leg, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (refers to a condition where a person experiences weakness or paralysis on the left side of their body due to a stroke (cerebral infarction) that damaged the right side of their brain, which controls the left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was sufficient staffing of the dietary department to ensure timely meal service for all residents when meals were served late to all units due to staffing shortages in the dietary department. The facility census was 94. Review of the document titled Mealtimes, provided by the facility, showed the following: -Breakfast 7:00 A.M. to 8:15 A.M.; -Lunch 11:30 A.M. to 1:00 P.M.; -Dinner 5:00 P.M. to 6:15 P.M. 1. During an interview on 11/21/23, at 8:27 AM, the Dietary Manager (DM) said the serving order of the meal carts was the Secure Unit, the Dining Room, Love 1 (100 hall), Hope (200 - 300 halls), and Love 2 (100 hall). 2. Review of Resident Council Minutes, dated 11/03/23, showed residents voice a concern with ,mealtimes getting later. 3. Review of Resident #34's Face Sheet, undated, in the electronic medical record (EMR) under the Resident tab showed the resident was admitted to the facility on [DATE]. Review of the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper food service practices were implemented in the kitchen to prevent the potential spread of food borne illness to all residents receiving meals in the facility when four residents (Residents #92, #200, #7, and #33) were served over easy non-pasteurized eggs creating risk for salmonella (bacteria) food borne illness; when bulk foods and refrigerated shakes were not labeled; when the dishwasher's wash temperature was below the minimum required temperature; when food from significantly dented cans was served, and when a dietary staff member failed to wear a hair covering in the kitchen. The facility census was 94. Review of the facility's policy titled Safe Food Handling, dated May 2015, showed the following: -Dietary employees will follow safe food handling guidelines to prevent the spread of foodborne illness; -Potentially hazardous foods should be thawed in the refrigerator; -Food items are to be labeled and dated when removed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide selected food and beverage choices for six residents (Resident #51, #92, #71, #84, #83, and #89) out of a total of 20 sampled residents and 10 supplemental residents when residents' food preferences and selections for meals documented on their tray cards were not followed. The facility census was 94. 1. During an interview on 11/19/23, at 9:42 A.M., the Dietary Manager (DM) said residents were provided meal choices daily and utilized an Anytime menu. When breakfast trays were distributed, residents were sent paper menus with the meal selections for lunch and dinner that day and for breakfast the following day. Residents marked on the paper menus which foods and beverages they wanted, and the menus were returned to the kitchen via the residents' returned breakfast trays. When the menus were received in the kitchen after breakfast, she wrote the residents' selections on their tray cards for lunch, dinner, and breakfast the next day.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a homelike environment to all residents when one resident (Resident #56) had a dresser with a broken drawer; when two residents (Residents #51 and #88) had broken blind slats; and when staff failed to maintain the Memory Care Unit in good repair. The sample size was 20 residents with a facility cenus of 94. 1. Observation and interview on 11/19/23, at 4:25 P.M., showed Resident #56's dresser drawer had a broken front panel on the right side of the dresser that prevented the resident from opening the drawer. The resident said he/she had requested several times that the drawer be repaired, but it was still broken. The drawer contained personal items and the resident was not able to open the drawer to access them. During an interview on 11/21/23, at 2:55 P.M. the Maintenance Director said that she was aware the resident's dresser needed repair. 2. Observation and interview on 11/19/23, at 5:28 P.M., showed Resident #51's room had five broken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare and serve palatable food to seven residents (Residents #92, #71, #34, #51, #12, #28, and #200) out of a total of 20 sampled residents and 10 supplemental residents, when the food was not hot, not flavorful, overcooked, and served without seasoning and/or without condiments when residents received their meal trays. The facility census was 94. Review of the facility's policy titled Food Temperatures, dated May 2015, showed hot foods should be at least 120 degrees F (Fahrenheit) when served to the resident. Review of the facility's policy titled Food Preparation and Distribution, dated May 2015, showed the Dining Services Department will prepare foods by methods that are safe and sanitary while conserving nutritive value as well as enhancing flavor. Food is prepared by methods that conserve nutritive value, flavor, and appearance. 1. Review of Resident Council Minutes, dated July 2023 to November 2023, showed the following: -Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment for all residents, staff and public when staff failed to ensure one of two exterior doors, on the secured dementia care unit, had proper weather stripping to prevent cold air, rodents, or bugs from entering the facility. The facility census was 94. 1. Observations on 11/19/23, at 9:53 A.M., of the secured dementia care unit, showed two exterior doors leading from the lounge out to a courtyard were noted to be missing weather stripping allowing a gap approximately 3/4th inches between the doors and approximately 7/16th inches underneath the doors. Four live crickets were observed on the floor in the lounge and two live crickets were observed in the dining room attached to the lounge. During an observation on 11/19/23, at 11:38 A.M., two crickets were observed in the tub/shower room across from the nurses' station and one cricket was observed in the second tub/shower room. During an interview on 11/20/23, at 3:33 P.M., the Maintenance Director confirmed the gap in the doors and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident #92), out of five sampled residents, resuscitation status as in accordance with the resident's and resident's wishes. The facility census was 94. Review of theCardiopulmonary Resuscitation (CPR - lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped), undated, document provided by the facility showed the following: -Purpose to establish circulation on a resident with absence of respirations and pulse; -Do not initiate CPR if a valid DNR (resident did not wish to receive CPR) order is in place. Review of the Advance Directive document, undated, provided by the facility showed the following: -The facility will respect advance directives in accordance with state law; -The facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to DNR. 1. Review of Resident #92's Face Sheet, undated, in the electronic medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for all residents when the staff failed to lock two tub/shower rooms in the dementia care unit where one resident (Resident #75), of 13 sampled residents, wandered continuously and routinely pushed on doors throughout the dementia care unit. The facility census was 94. 1. Review of Resident #75's Census Record, located under the Resident Census tab of the electronic medical record (EMR), showed the following: -admission date of 08/25/22; -Diagnoses included Alzheimer's disease early onset. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 11/02/23 and located under the MDS tab of the EMR, showed the resident was severely cognitively impaired and a wanderer. Review of the resident's Care Plan, dated 11/02/23, showed the following: -Tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety); -The goal was noted as I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to electronically transmit encoded Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) from the facility to the Centers for Medicare & Medicaid Services (CMS) system within 14 days after completion for four residents (Resident #1, Resident #3, Resident #4, and Resident #22 ) out of a sample of 19 residents selected for review. The facility had a census of 58 residents. Record review showed the facility did not provide a policy regarding transmitting MDS data. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -readmitted to the facility on [DATE]; -Diagnoses included anxiety disorder, chronic pain, and Alzheimer's disease. Record review of the resident's quarterly MDS assessment, due and completed on 8/24/21, showed staff encoded the MDS assessment data into the facility's system, but did not electronically transmit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinent care for one resident (Resident #20) and failed to assist two residents (Resident #3 and Resident #19) with toileting or incontinent care in a timely manner. The facility census was 58. Record review of the facility's policy titled Perineal Care, dated March 2015, stated the purpose of perineal care is to cleanse the perinium (the area between the anus and the genitalia) and to prevent infection and odor. 1. Record review of Resident #20's face sheet (brief resident profile sheet) showed the following information: -readmitted to the facility on [DATE]; -admitted to hospice services on 7/20/2021; -Diagnoses included generalized muscle weakness, dementia with behavioral disturbance, aphasia (loss of ability to understand or express speech) following stroke, hemiplagia (paralysis of one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following stroke, and chronic moderate kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility staff failed to ensure serving sizes met the approved menu when preparing pureed food for residents. The facility census was 58. Record review of the facility's Food Preparation and Distribution, dated May 2015, showed the following: -Recipes should be followed on each item prepared; -Adequate amount of food is prepared to serve residents, allowing for seconds; -Measured utensils are used to serve proportions as described on the menu. 1. Record review of the facility's puree menu showed residents should receive one slice of bread per resident for lunch on 9/16/21. Observations on 9/16/21, at 11:09 A.M., showed the following: -Dietary Aide (DA) D had the recipe book out and completed purees; -DA D put six pieces of bread into the blender and added milk; -DA D pureed until a correct blend then poured the bread into 8 small bowls and placed them in the cold side of the serving table. During in interview on 9/16/21, at 1:09 P.M., DA D said the following: -When completing purees, he/she should follow the recipe and he/she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #47 and Resident #56) were routinely assessed for the ability to safely smoke independently and to store their smoking supplies in their rooms. The facility census was 58. Record review of the Non-Smoking Facility-Resident Agreement, undated, showed the following information: -The purpose of the agreement is to verify understanding that the facility was a non-smoking facility upon admission. Residents of the facility who choose to smoke/use tobacco (including smokeless tobacco, cigarettes, vape (a device used for inhaling vapor containing nicotine and flavoring) cigarettes, etc) must agree and acknowledge the following: -Resident must sign out in the leave of absence (LOA) binder; -If the resident is not their own responsible party the active responsible party must give facility permission to allow resident to sign the leave of absence binder; -Resident will smoke at least 50 feet from building; -Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.